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When is it OK to hurt patient?

As mentioned, I am LOVING this orthopaedics block! My consultant has a reputation of being a scary screamer but so far she has been brilliant with me and my clinical partner and so life is good.

What is good about this placement is that my consultant is a shoulder specialist which means that most people who come to see her have impingement, instability, a-c pain, humerus fracture or a frozen shoulder. This might not seem very exciting but it has meant that we have become good at diagnosing and managing these complaints. On my GP block, every bloody patient that came had something different…you got your head around working out what the chest pain was due to and then they left and a new patient came in with a toe problem…..I liken the experience to swimming backwards in poo.

Anyway – in clinic this week, a 50 year old lady attended with severe shoulder pain. Her passive arm flexion and abduction was 60 degrees, after which active movement was possible but with horrid pain. We were asked to take a history from her, examine her, make a diagnosis and then present the case to the consultant, who would then come and examine her again and discuss treatment options.

I took her history and then started to examine her. After looking at her cervical spine movement, I began the arm movements, managing to get her flexion to 180 degrees, albeit with clear pain. In fact, the pain was so bad that she started crying and she wasn’t a wimpy lady – it was just clear that she was in agony. I decided at that point not to continue to abduct her arm because the other tests indicated that she had supraspinatus impingement which was likely to produce a painful arc. So I left the abduction and did some of the other examination which she managed, without reproducing too much of her pain.

When we left the room to go and find the consultant, my clinical partner voiced his concern with what I had just done. He felt that I should have continued with the full exam, despite the fact she was crying with pain. He felt that by not persisting, I had failed in my examination. I told him that I felt that continuing to examine her, despite pain and tears would actually be unethical. This didn’t go down terribly well with him but I stood my ground because although I might not be a font of medical knowledge, my nursing background has given me a lot of insight into patient care.

Since my first contact with patients as a medical student, I have been very aware of the fact that when we examine patients, it is usually for OUR benefit, not for the patient’s. We know so little that examining is how we learn, but in this case I knew that continuing with the exam was causing her significant pain and that once I had presented the case to my consultant, she would then have to go all through it again.

My clinical partner was not amused that I stood my ground on this one and I think the reason for this might be our backgrounds. He is an ex-physiotherapist and I think it’s fair to say that physio’s often cause pain, albeit for the good of the patient’s recovery!